Cedar Haven Operations LLC Dba Lake Forest Health

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide specialized rehabilitation services for 1 of 3 residents reviewed relative to physical therapy services, Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure services provided to residents met professional standards of nursing practice for 1 of 1 resident reviewed who had physician orders for thin liquids by spoon only and for obtaining vital signs every shift for 7 days, that were not followed, Resident ID #1.

Inspectors wroteBased on clinical record review, surveyor observation, staff and resident interview the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to an unidentified respiratory illness for 2 of 3 nursing units and affecting Resident ID #s 7, 18, 29, 34, 36, 59, 62, 64, and 97. Additionally the facility failed to routinely clean a BiPap machine (a noninvasive ventilation that helps you breathe) for Resident ID #1. Furthermore, the facility failed to follow transmission-based precautions for 3 of 6 resident's reviewed, Resident ID #s 6, 14, and 39.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to follow and implement a physician's order relative to the administration of insulin for 1 of 3 residents reviewed, Resident ID #3. Additionally, the facility failed to follow and implement physician's orders relative to the facility's Bowel Protocol for 2 of 2 residents reviewed who did not have a bowel movement (BM) for more than three days, Resident ID #s 8 and 77.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to implement and maintain an effective training program for all employees, consistent with their expected roles, as outlined in the Facility Assessment relative to education on the use and maintenance of Bi-PAp (A bilevel positive airway pressure machine- a type of noninvasive ventilation that helps individuals breathe by delivering pressurized air through a mask) and C-Pap (a continuous positive airway pressure machine- a type of medical device that is prescribed to treat sleep apnea by delivering a constant stream of pressurized air to keep the airways open during sleep) for 5 of 5 nurses reviewed, Staff C, E, G, H, and K.

Inspectors wroteBased on clinical record review, surveyor observation and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed for a fluid restriction, Resident ID #35.

Inspectors wroteBased on clinical record review, surveyor observation, and staff interview, the facility failed to ensure that each resident received adequate supervision and assistive devices for 1 of 1 resident reviewed for elopement, Resident ID #2.

Inspectors wroteBased on surveyor observation, clinical record review, resident, and staff interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen use, Resident ID #97.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that pain management is provided to residents who require such services, for 1 of 1 resident reviewed for pain management, Resident ID #12.

Inspectors wroteBased on clinical record review, resident and staff interview, the facility failed to keep all residents free from significant medication errors for 1 of 1 resident reviewed who received his/her roommate's medication in error, Resident ID #5 and for 1 of 1 resident reviewed whose medication was omitted, Resident ID #53.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented, relative to 1 of 1 resident reviewed for elopement, Resident ID #2 and for 1 of 1 resident reviewed for Narcan (a medication that can reverse an opioid overdose), Resident ID #28 and 1 of 1 resident reviewed whose medication was omitted, Resident ID #53.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, relative to the use of electronic monitoring for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, relative to use of Enhanced Barrier Precautions (EBP, use of gown and gloves for high contact activities) for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care, for 1 of 1 resident reviewed for significant medication errors, Resident ID #1. The failure of the facility to ensure that nursing staff followed established medication administration protocols, adhered to scope-of-practice requirements, and maintained safe medication-handling practices resulted in significant medication errors. This failure contributed to the resident receiving multiple medications not prescribed to him/her, requiring emergency intervention and a hospital transfer.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed who was administered an antipsychotic, antidiabetic agents, benzodiazepines (medications that are prescribed to slow down activity in your brain and nervous system), and narcotic medications that were prescribed for another resident, who required Emergency Medical Services (EMS), hospitalization, multiple doses of Narcan (a medication used to treat an opioid overdose) administration, and activated charcoal (a medication used to treat an overdose). These emergency interventions were necessary as a result of the medication errors involving Resident ID #1.

Inspectors wroteBased on record review, resident and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 1 resident reviewed, Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality, relative to not following physician's orders for 1 of 3 residents reviewed regarding obtaining weights, Resident ID #1.

Inspectors wroteBased on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed relative to a missed medication administration, Resident ID #2.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for administering nutrition via a gastrostomy tube (G-tube, a tube that is inserted through the wall of the abdomen into the stomach to deliver nutrition, fluids, and medication) for 1 of 2 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practice for 1 of 2 residents reviewed receiving nutrition via a gastrostomy tube (G-tube, a tube that is inserted through the wall of the abdomen into the stomach to deliver nutrition, fluids, and medication), Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for a fall resulting in a hospitalization, Resident ID #21 and for 1 of 1 resident reviewed for an injectable anti-psychotic medication, Resident ID #35.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed relative to a scheduled orthopedic appointment, Resident ID #55.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Enhanced Barrier Precautions (EBP; which requires the donning of (putting on) a gown and gloves during high-contact resident care activities), for 5 of 6 residents reviewed, Resident ID #s 4, 37, 82, 86, and 304 and for 2 of 2 residents reviewed for Covid-19, Resident ID #s 14 and 94.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents for 1 of 1 resident reviewed who requires frequent safety checks, Resident ID #21.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for withdrawal symptoms, Resident ID #98.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 6 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observations, record review, staff and resident interview, it has been determined that the facility failed to provide an environment that promotes maintenance or enhancement of his or her quality of life relative to providing activities of daily living (ADL) for resident's whose primary language is not the dominant language of the employee that was providing care for 2 of 4 residents reviewed, Resident ID #s 1 and 2.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to promote and facilitate self-determination through support of resident choice relative to weekly showers for 2 of 4 residents reviewed, Residents #1 and 3.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an accident for 1 of 3 residents reviewed for elopement, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 2 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide an ongoing program to support the residents in their choice of activities designed to meet their interests and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 4 of 4 residents reviewed for activities who reside on the North B Unit ( a secured/locked unit), Resident ID #s 4, 5, 6 and 7.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to promptly identify and intervene during acute changes in condition for 2 of 2 residents reviewed, Resident ID #s 1 and 2.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents, staff, and the public for 4 of 4 units observed.

Inspectors wroteBased on surveyor observation, staff interview, and record review, it has been determined that the facility failed to provide an ongoing program which includes group activities and/or one-on-one visits (1:1), on 3 of 4 units reviewed for activities including the specialized dementia unit, for 7 of 7 residents reviewed, Resident ID #s 7, 33, 65, 78, 86, 95 and 111.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 5 residents reviewed for respiratory care, Resident ID #s 7, 15, and 62.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 2 of 2 resident's reviewed for Extended Spectrum Beta-Lactamases (ESBL, an infection that is resistant to specific types of antibiotics), Resident ID #s 174 and 107, 1 of 6 residents reviewed for wound treatments, Resident ID #19 and the handling of soiled linen for 1 of 4 units and 1 of 1 laundry room.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination, did not receive the vaccination due to medical contraindications, or refusal for 5 of 7 residents reviewed, Residents ID #s 33, 34, 58, 66 and 104.

Inspectors wroteBased on surveyor observation, resident, and staff interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public relative to 3 of 4 units observed, affecting Resident ID #s 15, 22, and 47.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that services provided by the facility failed to meet professional standards of quality relative to a dressing observed on a resident, without a physician's order for 1 of 6 residents reviewed with a wound, Resident ID #73.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed for unnecessary medications, Resident ID #50.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures relative to notification of a practitioner for 1 of 7 residents reviewed, Resident ID #60.

Inspectors wroteBased on surveyor observation, record review, staff and resident interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents for 7 of 7 residents reviewed for smoking, Resident ID #s 1, 2, 3, 4 ,5, 6, and 7.